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Case of the Month

ClearCorrect Treatment of a Class II with Crowding and Deep Bite

A 59 year old woman presented with a Class II subdivision right malocclusion. Her chief concerns were the anterior incisal crowding. There was a considerable deep bite present with moderate maxillary and mandibular crowding. The lower arch was V-shaped with narrowing in the anterior segment. The maxillary central incisors were retroclined, reducing the support of the maxillary lip. The patient was missing several posterior teeth. The maxillary premolars were extracted for orthodontic treatment decades earlier. (See figures 1-7) The patient was planning on restoring the edentulous areas with either implants or fixed prosthetic after orthodontic treatment.

The patient’s periodontal status was good. There was generalized recession present with mild bone loss but probing depths were normal. There was no TMJ discomfort, and jaw movements were normal.

Two options for treatment were presented. One was an aligner therapy using an Unlimited ClearCorrect treatment, and the other was fixed-appliance treatment. Treatment goals for both options were the same, and included such things as leveling and aligning, reducing the deep bite, and preparing the patient for future treatment. The patient chose the first option as an esthetic option, as well as a way to help continue her periodontal regimen. She was motivated to wear the aligners and accepted treatment; she was glad that she wouldn’t have to wear metal braces at her age, and that it gave her comfort to know that she could take the aligners off when needed.

Diagnostic records were taken, and PVS impressions were made to fabricate the ClearCorrect aligners. A set of Starter Aligners were delivered to ease the patient into treatment without applying too much pressure. The patient was shown the diagnostic setup which we then approved. An estimated five phases with no inter proximal reduction was indicated.

A phase consists of four sets of aligners. These are numbered 1A, 1B, 1C, and then 1D. Each aligner is worn for three weeks at a time, and the patient is seen every six weeks in the office. Each phase is mailed to the office by ClearCorrect about one to two weeks prior to the patient’s appointment, during which the first set of aligners from each phase is seated. The patient is asked to wear the aligners for at least 20 hours a day. This should give the patient time for eating and proper oral hygiene without the aligners being seated.

Treatment Sequence and Detail

For the delivery of aligner 1C, engagers (or attachments) were placed on the patient’s teeth to help with torque and rotation control. An engager template was provided for easy placement. Engagers were placed on teeth #5, 12, 22, and 28. Heavy filled composite was used for the engagers, similar to what is used for a Class IV composite. I have found that a heavy filled composite resists attrition of the composite from the continual insertion and removal of the aligner. I used SDI glacier composite, color B1 in this case. It is very resistant to wear and has low shrinkage properties.

After Phase 4, the mandibular aligners were not seating as well. Specifically, the lower incisors were not rotating as needed into alignment. It was decided to take new PVS impressions, and a new Phase 5 was created at this point of her treatment, based on the most recent impressions submitted. This is one of the benefits of an Unlimited Clear Correct case. With the Unlimited case, a doctor can alter the aligners at any point in treatment at no additional charge, and without having the extra inventory of aligners on hand. Before the new impressions were taken, enamelplasty was performed to even out the edges of her teeth for esthetic purposes. This would also mean that the subsequent aligners would incorporate these changes in them.

The “new” Phase 5 fit well and treatment proceeded as normal. At the end of Phase 5, it was determined that an additional phase of treatment was needed to complete her treatment. While planning this phase, or refinement, it was determined that interproximal reduction would be needed within this refinement phase. After completion of the refinement phase, and after checking the alignment from these trays, it was determined that the patient was very pleased with the results the ClearCorrect treatment provided, and retainer aligners were requested (see figures 8-14).

Finishing and Retention

Clear thermoformed trays were fabricated by ClearCorrect and delivered. Results were good and some minor equilibration was performed. Due to the alignment of the maxillary incisors, and the increased torque needed to reduce her deep bite, there was some gingival recession that was apparent at the end of treatment. The patient maintained her Class I canines, her midlines were coincident, and she had good lateral excursions and anterior guidance. Her soft tissue profile was improved by increasing her maxillary lip support from the alignment of the maxillary incisors. The patient even noted that she was happy to have her confidence and smile back. The ClearCorrect aligners were a good alternative to fixed-appliances, and they made it easy for the patient to maintain oral hygiene throughout treatment.

Author Bio

Dr. Edward Davis (see figure 15) was born in Columbia and was raised in West Columbia, where he graduated from Airport High School in 1989. He attended the University of South Carolina where he received a BS in Biology. Dr. Davis completed his Doctorate of Dental Medicine at the Medical University of South Carolina. Following dental school he participated in a year of advanced dental training in the Graduate Residence Program at Columbia’s Palmetto Richland Memorial Hospital. Dr. Davis underwent training in the specialty of orthodontics at Saint Louis University’s Center for Advanced Dental Education, where he was awarded his certificate of Orthodontics and a MS in Oral Biology. Dr. Davis is currently one of the few board certified orthodontists practicing in Columbia metropolitan area and Orangeburg. Dr. Davis has been practicing orthodontics since January 2001. He actively participates in many professional organizations and strives to stay up to date with all of the latest advances in orthodontics and dentistry.